Monthly Archives: January 2015

In my ever continuing struggle to stay up to date, i thought I’d post today about something that was big news back in the Fall: Two pneumonia shots for seniors.

The old news was that everyone needed a pneumonia shot at age 65- one and done, we always thought. That “pneumonia shot” was really a vaccine against S. Pneumoniae, which causes meningitis, sepsis, along with the pneumonia that it was so nicely named for. The standard vaccine that we used in adults was the 23-Valent polysaccharide vaccine (PPSV23), brand name Pneumovax. This vaccine covers 23 serotypes of S. pneumoniae (that’s the 23 valent part of the name), and is made from polysaccharides found in the capsules of the bacterium (that’s the polysaccharide part of the name). This shot is great because it covers so many different serotypes. The downside of polysaccharide vaccines is that they can’t be given in children <2, they don’t provide lifelong immunity, and they don’t provide mucosal immunity (important because mucosal immunity promotes herd immunity). Studies on this vaccine show that it can prevent invasive pneumococcal disease, but may not be so great at preventing the noninvasive pneumococcal pneumonia.

These “polysaccharides” come from the S. pneumoniae capsule.

Enter the 13 Valent Conjugate Vaccine (PCV13), brand name Prevnar. This still uses polysaccharides from the pneumococcal bacteria, but attaches (conjugates) them to a “carrier protein”– in this case, a protein from diptheria. This carrier protein helps to rev up the immune system and induces mucosal immunity. After several exposures, this kind of vaccine will induce lifelong immunity. Before this year, we were commonly using this kind of vaccine in children (since the other one didn’t work), and in immunocompromised adults, but not in everyone. We know from this vaccine, and another conjugate pneumonia vaccine (PCV7), that immunizing children reduces the prevalence of those particular serotypes in adults (remember, mucosal immunity is a key to creating herd immunity).

The new news is that the PCV13 is now recommended for all adults >65. This recommendation came on the heels of a study performed by Pfizer (you can guess what they make) in the Netherlands. They studied 85,000 adults >65 who had never had a pneumococcal vaccine, and compared PCV13 to Placebo. There was a 75% reduction in vaccine-type pneumococcal disease in the vaccine group, and a 45% reduction in vaccine-type CAP. This was convincing enough for ACIP (the group that makes vaccine schedule recommendations). It is important to say again: participants in the study DID NOT have PPSV23 prior to the PCV13. Many of our patients have already had PPSV23.

We do know that PCV13 does induce an immune response in seniors, even if they have already had the PPSV23. It seems to be a “higher” immune response than the PPSV23, indicating that it may be the better vaccine between the two.

So what to do? Currently ACIP recommends that we give BOTH PCV13 and PPSV23 to our patients over 65. The ideal scenario would be to give the PCV13 (Prevnar) first, and then the PPSV23 (Pneumovax) 6-12 months later. This is what you should do for patients who have never had any pneumococcal vaccination, as well as those who you are revaccinating because they have turned 65. If your patient over 65 has already had PPSV23, then wait a year before giving the PCV13. See the handy chart below for potential scenarios

Pneumococcal vaccine status:

FIRST give:

THEN give:

None/Unknown

Prevnar 13(≥ age 65)

Pneumovax 23

(6 to 12 months after Prevnar 13)

Pneumovax 23Given AFTER 65th birthday

Prevnar 13(≥ 12 months after Pneumovax 23)

n/a

Pneumovax 23Given BEFORE 65th birthday

Prevnar 13

(≥ age 65 AND

≥ 1 year after Pneumovax 23)

Pneumovax 23(6 to 12 months after Prevnar 13 AND5 years after Pneumovax 23)

So what about paying for these vaccines? That is another sticky situation. Medicare currently pays forONE S. Pneumonia vaccine per lifetime– which now seems to run counter to ACIP guidelines. It will take a year or two for Medicare to catch up, so don’t expect this to change until about 2016. *UPDATED INFO: Medicare, BCBS and Viva are in fact paying for the PCV13 vaccine. My read of the Medicare website shows that the second pneumococcal vaccine will be covered if it is given 11 months after the first one. If your patient is new to Medicare, or hasn’t had any S. pneumoniae vaccines yet, give them the PCV13– it is more immunogenic and is better to give first. If your patient has already gotten a PPSV23while covered by Medicare, they will likely have to pay out of pocket ($100-$150) to get the PCV13. My advice is to wait until the Medicare guidelines catch up. After that, wait a year or so and give the PPSV23. If they have already had the PPSV23, then give the PCV13 the next year. It is safe to give the second shot as early as 8 weeks after the first one.

Here are some practice scenarios. Let me know which vaccine you would give, when, and why in the comments.

65 year old, no medical problems, never had a S. Pneumoniae vaccine

75 year old, Medicare patient, vaccinated with PPSV23 at age 65

65 year old with diabetes, new to Medicare, got PPSV23 at age 59 after diagnosis with DM

Like this:

As the new year comes, we are bombarded with resolutions, lists of trends to expect, and that last push to see the Oscar nominated films. It seems cheesy to get all introspective this time of year, but it is an opportunity to set our course and think about how we might measure our progress.

I challenge you to set 2-3 outpatient medicine goals for the rest of the academic year. If you let me know what they are, I’ll commit to helping you work on them. These might be medical knowledge related (like practice 3rd/4th line hypertension management), communication related (hone your motivational skills to get patients to exercise), or focus in on practice management (improve efficiency, learn billing). We can point them out with specific clinic patients, I can make up practice cases, or you can do the research and share it in AMR. We can touch base through the next few months to make sure we are on track.

My overarching goal is to make your clinic a more educational experience and give your some tangible skills that you can walk out of residency with. The first step to getting there is to figure out what those skills would be.